<div class=grid_18>
<div class=grid_10> 
    <div class=block-border> 
        <div class=block-header> 
            <h1>Edit Member's Personal Details</h1><span></span> 
        </div> 

        <form id=validate-form class="block-content form" action="edit" method=post>
                      
            <div class=_50> 
                <p><label for=textarea>Action No</label> 
                    <input id="nid" name="nid" class="required" class="input-xlarge" type="text" value="<?php echo $record['Pdetail']['nid'];?>"/>
                    <input type="hidden" id="nid" name="nid" value="<?php echo $record['Pdetail']['id'];?>"/></p>
            </div>   
                
            <div class=_50> 
                <p><label for=textarea>NHIS No</label>
                    <input id="nhis" name="nhis" class="required" type="text" value="<?php echo $record['Pdetail']['nhis'];?>"/></p> 
            </div>

            <div class=_50>
                  <p><label for=select>Title of Honour</label> 
                    <select name="toh" id="toh" class="required" type="text"> 
                        <option value="Please Select Title">Please Select Title</option> 
                        <option value="<?php echo $record['Pdetail']['toh'];?>"></option>
                        <option value="Mr">Mr</option> 
                        <option value="Mrs">Mrs</option> 
                        <option value="Ms">Ms</option> 
                        <option value="Dr/Mrs">Dr/Mrs</option>
                        <option value="Professor">Professor</option>
                        <option value="Pastor">Pastor</option>
                        <option value="Evangelist">Evangelist</option>
                        <option value="Eng">Eng</option>
                        <option value="Pharm">Pharm</option>
                        <option value="Honorable">Honorable</option>
                        <option value="Elder">Elder</option>
                        <option value="Deacon">Deacon</option>
                        <option value="Deaconess">Deaconess</option> 
                    </select> 
                </p>
            </div>

            <div class=_50> 
                <p><label for=textarea>Surame</label>
                    <input id="sname" name="sname" class="required" type="text" value="<?php echo $record['Pdetail']['sname'];?>"/></p>  
            </div>

            <div class=_50> 
                <p><label for=textarea>Middle Name</label>
                    <input id="mname" name="mname" class="" type="text" value="<?php echo $record['Pdetail']['mname'];?>"/></p>  
            </div>

            <div class=_50> 
                <p><label for=textarea>First Name</label>
                    <input id="fname" name="fname" class="required" type="text" value="<?php echo $record['Pdetail']['fname'];?>"/></p>  
            </div>

            <div class=_50> 
                <p><label for=textarea>Picture</label>
                    <input id="pix" name="pix" class="" type="blob" value="<?php echo $record['Pdetail']['pix'];?>"/></p> 
            </div>

            <div class=_50> 
                <p><label for=datepicker>Date of Birth</label>
                    <input id="dob" name="dob" class="" type="date" value="<?php echo $record['Pdetail']['dob'];?>"/></p>  
            </div> 

            <div class=_50> 
                <p><label for=textarea>Age</label>
                    <input id="age" name="age" class="" type="text" value="<?php echo $record['Pdetail']['age'];?>"/></p>  
            </div>

            <div class=_50> 
                <p><label for=textarea>Place of Birth</label>
                    <input id="pob" name="pob" class="" type="text" value="<?php echo $record['Pdetail']['pob'];?>"/></p> 
            </div>

            <div class=_50> 
                <p><label for=textarea>Country</label>
                    <input id="country" name="country" class="required" type="text" value="<?php echo $record['Pdetail']['country'];?>"/></p>  
            </div> 

            <div class=_50> 
                <p><label for=textarea>Region</label>
                    <input id="region" name="region" class="required" type="text" value="<?php echo $record['Pdetail']['region'];?>"/></p> 
            </div> 

            <div class=_50> 
                <p><label for=textarea>District</label>
                    <input id="district" name="district" class="" type="text" value="<?php echo $record['Pdetail']['district'];?>"/></p>  
            </div> 

            <div class=_50> 
                <p><label for=textarea>Town</label>
                    <input id="town" name="town" class="" type="text" value="<?php echo $record['Pdetail']['town'];?>"/></p> 
            </div>

            <div class=_50> 
                <p><label for=textarea>Profession</label>
                    <input id="profession" name="profession" class="" type="text" value="<?php echo $record['Pdetail']['profession'];?>"/></p>  
            </div>

            <div class=_50>
                  <p><label for=select>Marital Status</label> 
                    <select name="mstatus" id="mstatus" class="" type="text"> 
                        <option value="Select Marital Status">Select Marital Status</option> 
                        <option value="<?php echo $record['Pdetail']['mstatus'];?>"></option>
                        <option value="Married">Married</option> 
                        <option value="Divorced">Divorced</option> 
                        <option value="Engaged">Engaged</option> 
                        <option value="Widow">Widow</option>
                        <option value="Widower">Widower</option>
                        <option value="Bachelor">Bachelor</option>
                        <option value="Spinster">Spinster</option>
                    </select> 
                </p>
            </div>

            <div class=_50> 
                <p><label for=textarea>Church Membership No</label>
                    <input id="mshipno" name="mshipno" class="" type="int" value="<?php echo $record['Pdetail']['mshipno'];?>"/></p> 
            </div>

            <div class=_50> 
                <p><label for=textarea>Moblie Phone No</label>
                    <input id="mfon" name="mfon" class="" type="int" value="<?php echo $record['Pdetail']['mfon'];?>"/></p>  
            </div>

            <div class=_50> 
                <p><label for=textarea>Telephone Phone No</label>
                    <input id="tel" name="tel" class="" type="int" value="<?php echo $record['Pdetail']['tel'];?>"/></p>  
            </div>

            <div class=_50> 
                <p><label for=textarea>E-mail Address</label>
                    <input id="email" name="email" class="" type="text" value="<?php echo $record['Pdetail']['email'];?>"/></p>  
            </div>            

            <div class=block-actions> 
                <ul class=actions-left> 
                    <li><a class="button red" id=reset-validate-form href="javascript:void(0);">Reset</a></li> 
                </ul> 

                <ul class=actions-right> 
                    <li><input type=submit id="Save-Personal Details" class="button" value="Save Record"></li> 
                </ul> 
            </div> 
        </form> 
    </div> 
</div> 